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PSYCHOMEDIA
Telematic Review
Sezione: MODELLI E RICERCA IN PSICHIATRIA

Area: Medicina e Psicologia


Effect of psychological approach on new blood donors' vasovagal events: randomised controlled trial

Maria Marinozzi, Antonella Pagliariccio




INTRODUCTION
Vasovagal or neuro-cardiological syndrome triggered by abnormal autonomic response is defined as an episode of systemic hypotension characterized by bradycardia and peripheral vasodilatation (1, 2, 3). This phenomenon can occur when donating blood. Vasovagal events (VVE) include vasovagal reaction and syncope. A vasovagal reaction is an uncomfortable state manifested by paleness, weakness, dizziness, sweating, anxiety, nausea, vomiting, hypotension, and bradycardia. Syncope is defined as a transitorial loss of consciousness and posture that may or may not be associated to the symptoms of vasovagal reaction, incontinence, and convulsions (4). Verifying the possibility of avoiding vasovagal events triggered by donation is important, also because it has been shown that vasovagal symptoms and, quite simply, the sight of a donor fainting, decrease the likelihood of future donation (5, 6, 7, 8). Syncope, although occurring rarely, is feared because it may develop into cardiac arrest (9).Many researchers (10, 11, 12, 13, 14, 15) have studied the vasovagal events linked to blood donation in order to individualise the subjects at risk. Findings from these studies suggest that first donation, youth, and low body weight are significant predictors of vasovagal events. As regards weight, it has been shown that a previous successful donation mitigates the effects of this factor on the possible development of these phenomena (10). With regard to sex, the results are not univocal, (11, 14, 15) and as far as race is concerned it seems that Caucasian high-school students are more predisposed than African-American students (11). Blood pressure and pre-donation cardiac frequency seem to be unrelated to the phenomena (14). Up until now, by considering donors' physical characteristics only, it has been impossible to predict which donors will develop a reaction of this nature. It has also been affirmed that physical characteristics and variables linked to blood donors' health conditions are not associated with syncope (6). On the other hand, strong emotions such as like fear can provoke neurovegetative symptoms linked to the alarm reaction in its various manifestations (16). Any invasive medical procedure, such as the simple blood taking, produces an emotional reaction based on how the mind encodes that experience (17).It has been noted that psychological measures can be helpful in identifying high-risk donors (18). First-time donors with a higher alexithymia score are more anxious at donation, and more prone to complain about physical symptoms (19). Moreover, the application of psychological strategies, such as exposure to blood injection stimuli, distraction, and applied muscle tension, has produced some interesting results in other fields of research (20, 21, 22, 23, 24, 25). Fears of fainting and pain have been indicated as reasons not to donate (26, 27, 28). We also need to understand why only half of donors only donate once (29).

Objectives and hypothesis
The main goal of this research is to prevent vasovagal events at first donation, and therefore increase donor retention. Our hypothesis is that the emotions linked to donation, which is a stressful situation, are the main causes of these reactions. Consequently, we introduced a psychological interview into our everyday practise which allowed us to identify the disturbing emotions, fears, and stressor factors connected to donation. Also, at the same time, it enabled the donors to cope with the donation in the best possible way by activating their potentials. The rationale therefore was to use the effectiveness of the psychological interview to overcome fears or stressor factors linked to first donation, thus avoiding vasovagal symptoms.


MATERIALS AND METHODS

Participants
The eligibility criterion for participants was to be an aspiring donor physically suitable for donation.
Of the 460 donors who presented themselves, 71 were excluded at the outset because they were not suitable for donation according to current Italian transfusion law. Of the 389 remaining participant donors, 288 were treated psychologically to best cope with their first donation. The control groups of 101 donors were interviewed in the usual manner as prescribed by Italian law. All the new donors presenting themselves spontaneously to donate, without remuneration, were examined for selection for their first donation at one of theCollection Units of the Regional Blood Bank of the United Hospitals of Ancona ­ Italy. They were recruited in a completely random manner from 1st October 2001 to 31st October 2004. The follow-up lasted between 1 year and 4 years. The mean average was 30 months.

Method
During the standard interview the doctor refers to the questionnaire that the donor must complete by law. The donors answer questions regarding their family and personal anamnesis and their lifestyles. The donors are then medically examined and informed about the medical procedure for donation. The standard interview is used exclusively to test for physical suitability for donation. It is generally conducted by the doctor in a directive manner, using technical language. This interview lasts about 15-20 minutes. In the experimental situation the doctor conducts the standard interview using a psychological approach, in order to confront the emotional-affectional dynamics related to first donation, which may express themselves in unpleasant vasovagal symptoms. This approach is based on psychodynamics, integrating elements of brief and strategic psychotherapy. Directive injunctions and metaphors have proved to be particularly effective operative methods. (30,31,32,33,34,35,36,37,38,39,40). The interview lasts about 30-40 minutes. The doctor has some psychological training and there is no psychotherapeutic contract with the donor.

Psychological foundations of interview
Even though this type of interview does not have a fixed and impersonal scheme of standard questions and answers, it can be mentally individualised as having four phases in its dynamicity:

1. Identification of donor's experience
When speaking to the donors, the doctors adhere to the strategies brought into play by the donors themselves. This attentive listening transmits a feeling of acceptance and participation to the donors, as the doctors “collect” the donors' emotions and states of mind and act as container for them in this specific contest. It is crucial to know how to read the partially linguistic, non-verbal messages. Above all it is important to listen to the donors' emotional state in order to decipher their emotional reactions (transfer­counter transference). The emotive response of the donors' communication and the signs of what is not actually said often transmit messages that are a call for help. The donors are put in a condition in which they express worries that negatively influence their experience, characterised by:
- Dysfunctional thoughts linked to public places and prejudices about blood donation that the donor generally verbalises spontaneously. The mere correction of these thoughts, where they exist, stabilises the therapeutic alliance between doctor and donor. Relieving donors of a series of worries encourages them to cooperate with the doctors and see them as people who understand and help donors.
- Conscious fears linked to negative experiences which donors usually resist expressing because they are worried about demeaning the image the doctor may have of them, or because of personal difficulties in linking events to memories.
- Preconscious fears regarding negative but easily re-evocated past experiences, such as blood takings, hospital admissions or surgery which are likely to influence the current situation. If the first donation goes well it becomes a new experience that modifies the negative memory and stabilises a new sense of well-being, consolidating the desire to return and donate again (emotional re-programming).

2. Verbalisation and re-elaboration
What the donor communicates is sometimes expressed in a confused manner. The doctor picks up on the key contents of the communication, and relays these messages with a clarity and coherence that were originally lacking. The great responsibility of the doctors lies here in creating common ground. As the donors are worried about having to face physical discomfort it is important that the doctors talk to them in the simple, concrete, and incisive kind of language more suitable for containing emotions. In this way the emotive tone of the communication is changed. If this change in the donors is to be activated easily, the doctors must also guide them into resolving the difficulties by using metaphors. This allows donors to face up to and overcome their fears without even talking about them directly, whilst also gaining new security. The creative learning that leads donors to giving an adequate response to the specific situation is effected in this way. The doctor often uses metaphors by adhering to the same strategies that the donors themselves use to communicate with doctors, such as talking about other people as a way of talking about themselves, without directly exposing themselves. In this way, the doctor can also talk about another donor or another situation that the donor then spontaneously links to the present situation. With this technique the doctor suggests an appropriate behavioural response to the donor. Re-elaboration often uses metaphors which, because of their figurative content, are therapeutic tools. Using simple and incisive images, they can identify the way out of the problem and provoke new behaviour to interrupt the donor's dysfunctional rigid cognitive structure regarding the donation..

3. Order of change
To encourage the desired change in a short time, without necessarily reverting to insight, the doctor uses injunctive language. The use of simple descriptive language is effective in encouraging the donors to make concrete choices and decisions, a task that would otherwise be difficult. The voice's modulation expresses persuasion, competence, and safety. It transmits strength to the donors that they can then use to activate their desire for change. Short incisive messages are used, given as orders at times when explanations wouldn't be effective in holding back emotions and states of mind. Above all, they are used in alexithymic subjects.

4. Clarification and synthesis of the fundamental points of the interview
If the donors are to master this new mental order related to reorganisation of the thoughts and emotions during the interview, it will sometimes be necessary to synthesise the fundamental points that emerged. Our focus is on the favourable psycho-physical conditions that will lead to the donation being experienced positively. Weak points that may have come out during the interview are put into perspective. In this way the positive change is consolidated in a self-defining prophecy.

Statistics
The sample size was not chosen prior to starting the trial. Both the control group and the experimental group samples were made up by the number of people who spontaneously presented themselves in a trial period of three years.The discriminating factor is the psychological interview. It deals with a qualitative discriminator which introduces two different conditions both significantly correlated to the donor's behaviour, and related to two main outcomes: to return, or not to return. The statistical method used, permitted by the sample size, is the 99% confidence interval, i.e. with an error of first type less than 1%. This technique consists in estimating of the average universal value in an interval found between the sample average ± three times the standard deviation. The sample size is sufficient to guarantee a normal distribution of sample parameters. In our specific case the parameter to estimate is the proportion of the universe (which is a particular average) by corresponding sample value.

Random allocation sequence
The telephonists who made the appointments for the new donors were not aware of the trial. They didn't know which doctors were working on which days and the appointment was given according to the aspiring donor's requirements (shift duties, holidays, and illness). The assignment of the appointments was thus totally random.

Blinding
All donors who presented themselves and the doctors of the control group were unaware of the trial's existence. The traineddoctor-experimenter was obviously aware of the psychological method. All donors wereunawareof how the pre-donation interview was conducted.


RESULTS
The data referring to demographic and clinical characteristics of the donors is described in table 1.
Inthe experimental group, 257people (89.2%) became long-time donors, and only 4 (1.3 %) donors had a vasovagal reactionand didn't come back to donate again. In the control group, 46 people (45.5%) became long-time donors and 25 donors (24.8%) had a vasovagal event (4 donors had a syncope, and 21 donors had vasovagal reaction). From the calculations it can be deduced that for the experimental group the confidence interval is 99% between 83.71% and 94.69%. For the control group an estimate of the proportions of the universe is extracted P = 30.65% ł 60.35% (table 2). In the experimental group, 20 suitable aspiring donors never made their first donation (6.9%) and seven (2.4%) donated only once without any vasovagal symptoms. Nineteen suitable donors never donated (18%) and 11 (10.8%) donors donated only once without any reaction.

Tab. 1
Experimental group (288 units) Control group (101 units)
male 184 59
Female 104 42
Mean age (years) 31.2 28.3



Tab. 2
Experimental group
Units (%)
Control group
Units (%)
Long time donors 257 (89.2%) 46 (45.5%)
Non returning donors 31 (10.8%) 55 (54.5%)
Vasovagal events 4 (1.4%) 25 (24.8%)
99% confidence interval 83.71% ł 94.69% (sp = 1.83) 30.65% ł 60.35% (sp = 4.95)



CONCLUSION
In this controlled and randomized trial we have verified that the psychological treatment of the donor effectively reduced both the intensity and number of vasovagal events at first donation (1.3% versus 24.8%). It has confirmed its usefulness and effectiveness on donor retention, considering that about 89% of these became long-time. Furthermore the percentage of long-time donors in the control group (45%) is the same as in the data taking from the National Blood Registry (41). Unfortunately there are no national data about vasovagal events in first time donors. Statistics confirm the validity of these results, even though the raw data itself was immediately striking. Considering that the psychological approach was the only discriminator between the two groups of voluntary non-remunerated donors, we came to the following conclusions. The emotional reaction linked to first blood donation significantly influences the possibility of carrying out the donation successfully.In this sense the interview seems to be an effective communicative strategy that provides donors with the means to master their own emotions. By mobilising their own energies, they can muster the sense of well-being needed to cope with donation. If unpleasant effects are not experienced and the mind doesn't register any danger, then there will be a positive expectation regarding future donations. This will lead to donors repeating the experience with renewed motivation. On the contrary, any negative expectation produced after discomfort, drives donors away from something they experienced as unpleasant, if not dangerous. The psychological training gives the doctor the possibility of facing up to the donors' fears. The questions regarding the donor's physical characteristics were asked in such a way to create a communicative bridge. On this bridge emotions, experiences, and mental states can pass in both directions, together with medical information. The doctor's avoidance of dysfunctional interaction with donors makes the latter perceive that even if they do manifest negative thoughts or emotions they are not betraying the doctor's expectations. The doctor maintains the same openness and emotional availability in relation to the donor. In the communicative exchange doctors allow donors to understand that the information they have collected has been suitably decoded and used to prepare them for donation. A sense of satisfaction regarding the experience strengthens self esteem, and frequently, at the end of the donation, donors ask when they can next come back again. Even if the donors communicate their fear in the standard interview they often don't have an interlocutor that understands them and knows how to help. The donors adapt to the style of the interviewer, who tends to become emotionally detached and mask his or her true thoughts and experiences. It often happens that the doctors, although making the right technical decisions, don't know how to relate to the donor correctly. In some cases, the insufficient relational skill of the doctor could be one of the factors that involuntarily encourage the donor's emotional detachment from donation. It should be emphasised that increasing long term regular donors means increasing blood supplies and reducing infective risks for patients. We also consider this methodology useful for preventing vasovagal events linked to other invasive medical procedures that can alarm people and in some cases hinder the correct application of preventative medicine.

Acknowledgment: Special thanks to Professor Franco Mastrosanti for his help with the statistics.
(Faculty of Economy - University of Ancona).


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For more information:
Maria Marinozzi (psychoterapist).
tel.: 0039-71-2070572 mail address: marinozzi.m@libero.it
Antonella Pagliariccio (haematologist)
tel.: 0039-71-948669 mail address: a.pagliariccio@alice.it

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